Saturday, March 24, 2012

Thanks for the suggestions, Part 2

More goodies from the waiting room suggestion box.



Now, I understand that it can get boring for your kid to be in the waiting room. I have no problems with her doodling on one of the papers. However, is it really necessary to actually put it in the suggestion box?


Margie is one of our awesome front desk receptionists. I have no argument with this suggestion. Margie for President!!!

Sunday, March 18, 2012

Dear NH Senate: Please Stay Out of My Exam Room

I try to keep my practice of medicine and my politics separate.  I wish that others, specifically the NH State Legislature, would do the same.  Especially when the person introducing a certain bill A) doesn't have a license to practice medicine, B) clearly believes everything she reads on the internet, and C) has no idea what the hell she is talking about.

So, here we go (deep breath, stepping onto my soapbox).

I'm talking about HB 1659-FN. This bill was sponsored by Rep. Jeanine Notter (R- Merrimack) and was passed by the NH House on March 15.  It's called, apparently without a bit of irony, the Women's Right to Know Act.

Oh, where to even start with this...


I. “Abortion” means the act of using or prescribing any instrument, medicine, drug, or any other substance, device, or means with the intent to terminate the clinically diagnosable pregnancy of a woman with knowledge that the termination by those means will with reasonable likelihood cause the death of the unborn child. Such use, prescription, or means is not an abortion if done with the intent to:
(a) Save the life or preserve the health of an unborn child;
(b) Remove a dead unborn child caused by spontaneous abortion; or
(c) Remove an ectopic pregnancy.
OK, (a) (b) and (c) are also abortions.  They are.  I don't care what your intent is, the outcome is the same.  You don't get to change the definition to suit your political needs.

132-B:4 Informed Consent Requirement. No abortion shall be performed or induced without the voluntary and informed consent of the woman upon whom the abortion is to be performed or induced. Except in the case of a medical emergency, consent to an abortion is voluntary and informed if and only if:I. At least 24 hours before the abortion, the physician who is to perform the abortion or the referring physician has informed the woman, orally and in person, of the following:(a) The name of the physician who will perform the abortion;(b) Medically-accurate information that a reasonable patient would consider material to the decision of whether or not to undergo the abortion, including (1) a description of the proposed abortion method; (2) the immediate and long-term medical risks associated with the proposed abortion method including, but not limited to, the risks of infection, hemorrhage, cervical or uterine perforation, danger to subsequent pregnancies, and increased risk of breast cancer; and (3) alternatives to the abortion;(c) The probable gestational age of the unborn child at the time the abortion is to be performed;(d) The probable anatomical and physiological characteristics of the unborn child at the time the abortion is to be performed;(e) The medical risks associated with carrying her child to term; and(f) Any need for anti-Rh immune globulin therapy if she is Rh negative, the likely consequences of refusing such therapy, and the cost of the therapy.II. At least 24 hours before the abortion, the physician who is to perform the abortion, the referring physician, or a qualified person has informed the woman, orally and in person, that:(a) Medical assistance benefits may be available for prenatal care, childbirth, and neonatal care, and that more detailed information on the availability of such assistance is contained in the printed materials given to her and the streaming video as described in RSA 132-B:5.(b) The printed materials and streaming video in RSA 132-B:5 describe the unborn child and list agencies that offer alternatives to abortion.
 Informed consent is good.  I'm all for it. However, the key word is informed- meaning that people are provided with unbiased scientifically accurate information.  I'll get back to this whole breast cancer thing in a minute.  My problem with the above bolded material is that doctors are required to describe the "probable anatomical and physiological characteristics of the unborn child" and that the patient is required to watch a video that describes the "unborn child."  First of all, there is no medical need here.  The characteristics of the fetus are not really relevant to the procedure that the patient will undergo.  I have a problem with the term "unborn child."  It's a fetus.  That's the medical terminology.  "Unborn child" is unnecessarily inflammatory and political.  I have not seen the streaming video referred to in the bill, and I have searched everywhere online for it.  I can only assume, and I think it's a good assumption, that it has an anti-abortion bias, given the inflammatory term "unborn child," in its description.


OK, on to this whole "abortion causes breast cancer" nonsense.  This is what the bill says:
(e) Materials that inform the pregnant woman that there is evidence of a direct link between abortion and breast cancer. It is scientifically undisputed that full-term pregnancy reduces a woman’s lifetime risk of breast cancer. It is also undisputed that the earlier a woman has a first full-term pregnancy, the lower her risk of breast cancer becomes, because following a full-term pregnancy the breast tissue exposed to estrogen through the menstrual cycle is more mature and cancer resistant. In fact, for each year that a woman’s first full-term pregnancy is delayed, her risk of breast cancer rises 3.5 percent. The theory that there is a direct link between abortion and breast cancer builds upon this undisputed foundation. During the first and second trimesters of pregnancy the breasts develop merely by duplicating immature tissues. Once a woman passes the thirty-second week of pregnancy (third trimester), the immature cells develop into mature cancer resistant cells. When an abortion ends a normal pregnancy, the woman is left with more immature breast tissue than she had before she was pregnant. In short, the amount of immature breast tissue is increased and this tissue is exposed to significantly greater amounts of estrogen—a known cause of breast cancer. Women facing an abortion decision have a right to know that such medical data exists. At the very least, women must be informed that it is undisputed that pregnancy provides a protective effect against the later development of breast cancer.

I don't dispute that earlier pregnancy is associated with a lower lifetime risk of breast cancer. That's where my agreement with the above text ends.  The most influential article promoting this theory was written by one Joel Brind, PhD.  Full text here. This study was a meta-analysis, which is generally one of the weakest types of studies.  A meta-analysis pools data from a bunch of different studies, using that data to support or refute a new hypothesis.  A good summary of the advantages and weaknesses of meta-analyses can be found here.  This is an excellent critique of Brind's paper which outlines its many flaws.  Not surprisingly, anyone with an anti-abortion agenda was quick to latch onto these results.   Just as quickly, more research began to be produced, which almost uniformly refuted Brind's finding.  This is one of the best- it looks at the records of 1.5 million Danish women and shows no link between abortion and breast cancer. This is another excellent one.  It is a case-control study- meaning it matches cases (women who have had abortions) with matched controls (women who have not had abortions but otherwise have similar ages and medical histories).  It showed no link between abortion and breast cancer.  In 2003, the National Cancer Institute held a symposium on pregnancy, abortion, and breast cancer.  Dr. Brind was the only researcher who supported an abortion-breast cancer link.

Want more?  Here you go! http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17111259&ordinalpos=8&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=12800205&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=12646509&ordinalpos=35&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

There's still more.  Lots more.  If you would like links to them, please email me.


In summary, the scientific evidence is overwhelming- abortions do not cause breast cancer.

Representative Notter appears to have little understanding of medical science.  For example, she believes that birth control pills somehow cause prostate cancer in men.


She has a clear agenda.  I don't want her agenda in my exam room.  Neither should you.  No matter what your feelings are surrounding abortion, let's keep bad science and bad politics out of the doctor-patient relationship.

Friday, March 16, 2012

Study of the Week- Pap Smears

The US Preventative Services Task Force (USPSTF) has finally caught up with the American College of Obstetricians and Gynecologists.  In the past, guidelines recommended annual Pap smears.  In 2009, ACOG recommended that Paps be done only every 2 years in low-risk women and every 3 years in women who have tested negative for HPV.  I've been following those guidelines since 2009.  The USPSTF has finally updated their recommendations to reflect the newest evidence.  You can read the complete article here.

So, what is a Pap test?  A Pap smear (named for Dr. Papanicolau) is a test for cervical cancer.  A small brush is used to scrape some cells off the cervix (the tip of the uterus).  A pathologist then looks at the cells to determine if any are abnormal.  The Pap smear is an incredibly effective screening test for cervical cancer- one of the best screening tests out there.  It's rare to see a woman die of cervical cancer these days, thanks to Pap smears.

However, cervical cancer is slow growing.  It first shows up as abnormal cells, then progresses a bit to low grade and high grade lesions in several stages.  These lesions often regress on their own, as the body's immune system fights them.  Rarely, a lesion will actually progress to cancer.  The problem with yearly Paps is that they catch all these abnormal cells, and that leads to biopsies. These biopsies, if abnormal, might lead to an excision of the area- this can lead to complications.  The evidence shows that a time span of 3 years is fine to catch lesions that are likely to progress to cervical cancer.  Keep in mind- this recommendation is only for low risk people- meaning someone without a history of abnormal paps and without multiple partners (cervical cancer is caused by the HPV virus, which is spread by sexual contact).

A Pap test does not test for uterine cancer or ovarian cancer.

A Pap test is NOT necessary to get birth control pills.  Never has been, never will be.

A Pap test does not test for sexually transmitted diseases.

The NY Times also reported on the new recommendations.  I always get a kick out of the reader comments in the health sections.  It contains gems such as this:

The assault on women's health continues. These guidelines and this article reflect everything that is wrong with both healthcare and journalism today. The recommendations were made based on opinion only, there are NO DATA to support these revisions. The PAP smear has been and always will be THE single most cost effective caner screening tool, BAR NONE! It's value, like any good screening tool, relies on the test being performed at frequent intervals.

We need to stop playing into the HPV hype being foisted on us by Merck. Cervical cancer of the squamous type is rare in the US now because of the success of annual PAP smears. So much so that adenocarcinoma of the cervix, which is completely unrelated to HPV and much more aggressive and faster growing has replaced the regular (squamous) type of cervical cancer as the leading cause of cervical cancer deaths in the US.

The committee's own press release states that most women with cervical cancer in the US have either never been screened or have not had a PAP smear in the past 5 years. This has been true for decades, and flies in the face of the logic of their own recommendations. The purpose of the PAP is to detect changes BEFORE they become cancerous. It we wait five years, by the time the diagnosis is made, it's too late.

As journalists you have an obligation to due diligence. Please follow the money trail to discover what is really behind the new guidelines. Millions of women will thank you.

This is another good one:
Cervical cancer is cancer and a woman can get it at any age. A pap smear should be part of an annual exam period. Are Insurance Companies going to do away with annual exams as well to save money for themselves. Greed is going to kill us all.

And this one:

It's quite obvious that insurance companies are behind the effort to restrict cancer screenings for the public, once again putting profits before human lives. We've heard the same nonsense regarding mammograms and PSA tests. First they start out telling us we don't need cancer screenings as often, then their next step will be to deny coverage for tests done more frequently than they want. We all know that cancer can spread like wildfire and these assertions don't make any sense. Yet another example of disgusting corporate greed.

I love it when people make up their own facts to suit an agenda.  I promise you, these new recommendations are not part of some deep, dark conspiracy to undermine women's health.  It's not being foisted on the American public by greedy insurance companies or doctors.

It's just good medicine.  That's it.  Sometimes it is that simple.
 
 

Tuesday, March 13, 2012

Let's Get Ready to Run!



It's that time of year, folks.

We're gearing up for the 8th annual Beacon Runner's season (AKA "Marni's Army).  This is geared to ALL levels- from the rank beginner to regular runner.

If you are interested in completing a 5K race, check out the information session-

March 15
6:00 PM
155 Borthwick Avenue
East Building, 3rd Floor Conference Room


Feel free to email me with questions- either click the "Contact Me" button on the bottom of the page, or email me at beacon runner@yahoo.com

Tuesday, March 6, 2012

More Mommy Wars

I came upon a blog post today entitled "Do yourself a favor.  Don't have a baby during residency."  It's by an anesthesiologist named Karen Sibert.  Some of you might have read her Op-Ed piece in the NY Times back in June.  That one was called, "Don't Quit Your Day Job," and basically said that women are screwing up the medical profession since too many of them work part time.  According to her, medicine requires a singular commitment, to the exclusion of all other pursuits.  She actually said in the NY Times piece that women applying to medical school should be asked to consider the potential conflicts between parenthood and medicine. 

Don't bother asking the men.  Apparently their responsibility ends just after insemination of the egg. 

Her blog post today starts off by enumerating the multiple ways that residency programs are burdened by a resident having a baby.  Now, please bear in mind that these women are not taking off months and months of luxurious leave.  The women that I know who had kids during residency took off four weeks (their normal yearly vacation allotment).  So, in reality, they didn't take off any more time than any other resident, although they did take it in one block, rather than the usual 2 two week blocks.  Since there is generally 9 months warning before the baby makes an appearance, it left plenty of time for scheduling coverage to be arranged. I should know.  I was chief resident for a year and was in charge of the residents' schedules.  Women having babies was no problem.  You know what was a problem?  When a resident got hit by a cab crossing 7th Avenue and had a bad leg fracture.  She was out of work for 8 weeks without any notice.  However, everyone dealt with it and provided coverage.  My point is that bad things can happen to anyone at any time requiring time off.

She then makes the patently ridiculous comment that there is no rush to have kids.  She actually implies that fertility does not decline as people hit their 30s, which is just plain wrong.

Her last point is that for women, having a baby is some sort of achievement to check off on life's to-do list.  You watch your friends have babies, and you get infected by baby fever, running out to get knocked up.  I just have no words to describe my feelings regarding that idea.

Now, I didn't have kids until I was done with residency.  I didn't get married until I was 28, and I had my first child at 33.  I was lucky, with both kids.  I had no problems with fertility and very easy pregnancies. I was very, very lucky.  Unfortunately, many of my friends from med school and residency have not been so lucky.  Infertility is a common issue among us, and for many it comes down to having waited too long.  There is no "right" time to have a baby.  I say, to all you residents and med students out there- if you want kids, go for it.  Don't listen to Dr. Sibert.  Don't wait (unless you want to).  In 10 years, no one from your residency will even remember that they had to cover for you while you were on your pathetic 4 week "maternity leave."  And you will have the joy of your children forever.

Just one more comment, and then I'll step off my soapbox.  If I had to choose the one thing that has made me a better doctor...it was becoming a parent.  It made me more patient, more empathetic, and more understanding of my patients' needs.  It is an experience that can in no other way be duplicated.